ShiftMed - Missed Punch Form

Missed Punch Form

As an employee of ShiftMed, please fill out this form only if you have worked a shift that requires adjustment. Please note, since this is a manual submission, there will be a longer processing time than typical payroll. For more details, see our Help Center here: https://help.shiftmed.com/en/articles/5492131-issues-with-clocking-in-and-out
Please Select the Type of Form (what type of Facility?):
Name

First NameLast Name
Your Phone Number
Format: (000) 000-0000.
Facility Name
**Please only select a facility name from the dropdown**
Facility Name
Please select one
Genesis Facility
California Facility
Date of Shift

MonthDayYear
Clock In Time

Hour Minutes

AM/PM Option
Break

Hour Minutes

AM/PM Option
Break Duration
Clock Out Time

Hour Minutes

AM/PM Option
Meal Break 1 Taken
Meal Break 1 Time

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Meal Break 1 Waiver
Meal Break 2 Taken
Meal Break 2 Time

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Meal Break 2 Waiver
Guaranteed Shift
Reason for missed punch
Detailed Reason for Missed Punch
File Upload - Make sure to submit a Genesis-Specific Form (can be found at the facility) and you must turn in this form to the facility scheduling team so it can be approved and adjusted

Cancelof
Should be Empty: